Snapshot A 28-year-old male was hit by a car while crossing the road. He sustained abrasions to the face, hands, and bruising over both iliac crests. Blood pressure is 90/55 mmHg and pulse is 110/min. Two large bore IVs are inserted and he was given 1L of Lactated Ringer's, and 2L of crossmatched pRBCs. Scrotal and perineal ecchymosis and swelling, blood at the urethral meatus, and bladder distension up to the umbilicus are present. AP radiographs of the pelvis reveal pelvic fracture (bilateral pubic rami fracture). Retrograde cystourethrogram shows a torn posterior urethra; a suprapubic catheter and a pelvic binder are applied. Introduction Genitourinary trauma involves kidney, bladder, and/or urethra 80% is from blunt trauma (MVCs, assaults, falls, crush) vs 20% penetrating (GSW/SW) Blunt trauma to genitourinary organs is associated with pelvic fracture in 97% cases Urethral injury etiology can be divided by posterior and anterior urethra posterior: junction of membranous and prostatic urethra is common site of injury login to view 1 more bullet anterior: straddle injury causing crush injury to bulbar urethra against pubic rami iatrogenic: instrumentation, penile fracture Presentation History mechanism of injury hematuria, blood on underwear dysuria, urinary retention prolonged labor and delivery login to view 1 more bullet Physical exam abdominal/flank pain, CVA tenderness, upper quadrant mass, perineal lacerations DRE: sphincter tone, position of prostate, presence of blood scrotum: ecchymoses, lacerations, testicular disruption, hematomas females: bimanual/speculum exam bladder login to view 2 more bullets urethra login to view 5 more bullets Evaluation Pelvis: radiograph with AP, inlet, and outlet views Urethra: retrograde urethrogram (RUG) if blood at meatus, do NOT insert Foley catheter; perform RUG first Bladder: urinalysis, urethrogram, retrograde cystoscopy +/- cystogram Ureter: retrograde ureterogram Kidney: intravenous pyelogram, CT scan (if hemodynamically stable) Treatment Primary and secondary survey with resuscitation (massive transfusion protocol for hemodynamically unstable patients Pelvis: mechanical stabilization of pelvis pelvic binder login to view 1 more bullet external fixator login to view 1 more bullet FAST (Focused assessment with sonography for trauma) exam to assess for intra-abdominal fluid login to view 4 more bullets Pelvic angiography and embolization of bleeding vessels may also be performed in hemodynamically stable patients who have evidence of active bleeding on a CT scan of the abdomen/pelvis login to view 2 more bullets Urethra: based on location of tear seen on retrograde urethrogram anterior: conservative management login to view 1 more bullet posterior: suprapubic cystostomy (avoid catheterization) +/- surgical repair Bladder: based on extra vs intraperitoneal rupture extraperitoneal login to view 2 more bullets intraperitoneal login to view 1 more bullet Ureter: ureterouretostomy Kidney: depends on grade of hematoma / laceration and HD stability minor: conservative management major: surgical repair